Worksite-based intensive lifestyle therapies for diabetes remission
Authors: Krista A. Varady, Shuhao Lin, Vanessa M. Oddo
Journal: Cell Reports Medicine (2022)

In a randomized controlled trial, Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar examined the effects of a worksite-based intensive lifestyle therapy on body weight, glycemic control, and diabetes remission, in adults with obesity and type 2 diabetes. In a randomized controlled trial, Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar examined the effects of a worksite-based intensive lifestyle therapy on body weight, glycemic control, and diabetes remission, in adults with obesity and type 2 diabetes. Main textSince adults spend most weekday waking hours at work, worksite interventions are uniquely positioned to improve employee health.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar These wellness programs can also benefit the company by lowering healthcare costs, while boosting employee productivity. Since the passage of the Affordable Care Act, the availability of worksite wellness programs has increased, in part, due to the law's incentives for companies to implement such programs. Current estimates suggest that 84% of large companies (200 + employees) in the US provide a program in at least one area: smoking cessation, weight management, and behavioral or lifestyle coaching.3Kaiser Family Foundation2019 Employer Health Benefits Survey.2019https://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019Google Scholar However, most worksite-based programs result in only modest weight loss, likely because interventions tend to be low or moderate intensity and provide minimal supervision.In a recent randomized controlled trial by Yoshino et al.,1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar adults with obesity and type 2 diabetes were assigned to one of two work-based interventions: intensive lifestyle therapy or standard care. The intensive therapy group met weekly with a dietitian to receive personalized diet and behavioral weight loss counseling. The energy intake goal for this group was adjusted weekly to achieve 0.5%–1.0% weight loss and >10% weight loss over 8 months. Meal replacements were supplied to help meet energy intake targets. In addition, the intensive lifestyle group participated in endurance and resistance exercise four times per week for 60 min per session. In contrast, the standard care control group received basic diet and physical activity instructions, based on American Diabetes Association guidelines.4American Diabetes AssociationStandards of medical care in diabetes-2022 Abridged for Primary care Providers.Clin. Diabetes. 2022; 40: 10-38https://doi.org/10.2337/cd22-as01Crossref PubMed Google Scholar This group had minimal contact with the study team and only interacted with interventionists once per month for clinical measurements.After 8 months of treatment, the intensive lifestyle therapy group achieved 17% weight loss, with individual results ranging from 6% to 29%. Fat mass and visceral fat mass decreased while lean mass was maintained. Diabetes medication use decreased by 61% from baseline, HbA1c was reduced by 0.9%, and three participants achieved diabetes remission. Improvements in intrahepatic triglyceride content, pancreatic beta-cell function, cardiorespiratory fitness, and muscle strength were also noted. However, none of these benefits were observed in the standard care control group because the body weights of these participants remained stable.This study has several strengths. First, the intensive therapy included both diet and behavioral counseling. The former is essential to improve diet quality and the latter is crucial to modify behaviors that contribute to weight regain. Both of these counseling components are vital for long-term weight and glycemic control and should be incorporated into all work-based interventions.5American Diabetes Association Professional Practice Committee8. Obesity and weight management for the Prevention and treatment of type 2 diabetes: Standards of medical care in diabetes-2022.Diabetes Care. 2022; 45: S113-S124https://doi.org/10.2337/dc22-S008Crossref PubMed Scopus (30) Google Scholar Second, the participants met with study personnel on a weekly basis. This high level of interaction between subjects and the study team likely played a major role in the extreme amount of weight loss (17%) observed in this trial. Third, the intensive therapy included both an endurance and resistance training component. Exercise plays an important role in maintaining muscle mass during weight loss. In the absence of exercise, approximately one-quarter of the total weight lost is lean mass.6Willoughby D. Hewlings S. Kalman D. Body Composition Changes in weight loss: Strategies and Supplementation for maintaining lean body mass, a Brief review.Nutrients. 2018; 10https://doi.org/10.3390/nu10121876Crossref Scopus (45) Google Scholar Because the intensive lifestyle group was exercising four times per week, they were able to lose a significant amount of body weight without losing any lean mass. Maintenance of muscle mass is crucial for preserving resting metabolic rate,7Stiegler P. Cunliffe A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss.Sports Med. 2006; 36: 239-262https://doi.org/10.2165/00007256-200636030-00005Crossref PubMed Scopus (284) Google Scholar which can help with long-term weight management.Although the study has several strengths, some limitations were also noted. For example, the sample size was very small (n = 23) compared to other studies in the field that involved 60 to 5828 participants.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar In addition, the very low dropout rate in the intensive lifestyle group (8%) is considerably different from previous reports that show dropout rates ranging from ∼20% to 30%.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The degree of weight loss observed by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar (17% from baseline) is also very high compared to other studies in the field, which report losses of ∼1%–5% from baseline. It is also striking that every subject in the intensive group lost weight, with the lowest amount of weight loss being 6% and the highest being 29%. In comparison, other trials show that approximately 20%–40% of participants are not responsive to therapy and lose no weight.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The adherence data, which indicates that participants attended 98% of weekly diet counseling sessions and 92% of exercise sessions over 8 month, also seems quite high.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar These concerns put into question the generalizability of the findings. This study seems to have recruited a highly motivated group of people with type 2 diabetes, which may not be representative of this population. Additionally, we question the feasibility of delivering such an intensive intervention to hundreds or even thousands of employees or those who do not work in a traditional office setting (e.g., truck drivers, nurses). In view of this, these findings should be interpreted with caution as these data are considerably different from what has been reported previously.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google ScholarAnother concern is the lack of follow-up for the intensive lifestyle group. It is truly impressive that these participants were able to lose so much weight, improve multiple parameters of metabolic health, and even achieve diabetes remission. However, without proper long-term care,10Flore G. Preti A. Carta M.G. Deledda A. Fosci M. Nardi A.E. et al.Weight maintenance after dietary weight loss: systematic review and meta-analysis on the Effectiveness of Behavioural intensive intervention.Nutrients. 2022; 14https://doi.org/10.3390/nu14061259Crossref Scopus (3) Google Scholar most of these individuals will regain their weight and their diabetes risk factors will return to baseline levels. This study would have been stronger if it included a long-term follow-up component, where subjects were contacted months or years after the trial to see if they were still following the interventions in the absence of intensive monitoring. These data would help to clarify whether the benefits of this workplace lifestyle initiative can be maintained over years.Challenges aside, the study by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar highlights the potential of worksite wellness programs to assist employees in managing their weight and improving metabolic health outcomes. This trial suggests that intensive work-based programs can play a critical role in helping to combat the obesity and diabetes epidemic. Main textSince adults spend most weekday waking hours at work, worksite interventions are uniquely positioned to improve employee health.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar These wellness programs can also benefit the company by lowering healthcare costs, while boosting employee productivity. Since the passage of the Affordable Care Act, the availability of worksite wellness programs has increased, in part, due to the law's incentives for companies to implement such programs. Current estimates suggest that 84% of large companies (200 + employees) in the US provide a program in at least one area: smoking cessation, weight management, and behavioral or lifestyle coaching.3Kaiser Family Foundation2019 Employer Health Benefits Survey.2019https://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019Google Scholar However, most worksite-based programs result in only modest weight loss, likely because interventions tend to be low or moderate intensity and provide minimal supervision.In a recent randomized controlled trial by Yoshino et al.,1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar adults with obesity and type 2 diabetes were assigned to one of two work-based interventions: intensive lifestyle therapy or standard care. The intensive therapy group met weekly with a dietitian to receive personalized diet and behavioral weight loss counseling. The energy intake goal for this group was adjusted weekly to achieve 0.5%–1.0% weight loss and >10% weight loss over 8 months. Meal replacements were supplied to help meet energy intake targets. In addition, the intensive lifestyle group participated in endurance and resistance exercise four times per week for 60 min per session. In contrast, the standard care control group received basic diet and physical activity instructions, based on American Diabetes Association guidelines.4American Diabetes AssociationStandards of medical care in diabetes-2022 Abridged for Primary care Providers.Clin. Diabetes. 2022; 40: 10-38https://doi.org/10.2337/cd22-as01Crossref PubMed Google Scholar This group had minimal contact with the study team and only interacted with interventionists once per month for clinical measurements.After 8 months of treatment, the intensive lifestyle therapy group achieved 17% weight loss, with individual results ranging from 6% to 29%. Fat mass and visceral fat mass decreased while lean mass was maintained. Diabetes medication use decreased by 61% from baseline, HbA1c was reduced by 0.9%, and three participants achieved diabetes remission. Improvements in intrahepatic triglyceride content, pancreatic beta-cell function, cardiorespiratory fitness, and muscle strength were also noted. However, none of these benefits were observed in the standard care control group because the body weights of these participants remained stable.This study has several strengths. First, the intensive therapy included both diet and behavioral counseling. The former is essential to improve diet quality and the latter is crucial to modify behaviors that contribute to weight regain. Both of these counseling components are vital for long-term weight and glycemic control and should be incorporated into all work-based interventions.5American Diabetes Association Professional Practice Committee8. Obesity and weight management for the Prevention and treatment of type 2 diabetes: Standards of medical care in diabetes-2022.Diabetes Care. 2022; 45: S113-S124https://doi.org/10.2337/dc22-S008Crossref PubMed Scopus (30) Google Scholar Second, the participants met with study personnel on a weekly basis. This high level of interaction between subjects and the study team likely played a major role in the extreme amount of weight loss (17%) observed in this trial. Third, the intensive therapy included both an endurance and resistance training component. Exercise plays an important role in maintaining muscle mass during weight loss. In the absence of exercise, approximately one-quarter of the total weight lost is lean mass.6Willoughby D. Hewlings S. Kalman D. Body Composition Changes in weight loss: Strategies and Supplementation for maintaining lean body mass, a Brief review.Nutrients. 2018; 10https://doi.org/10.3390/nu10121876Crossref Scopus (45) Google Scholar Because the intensive lifestyle group was exercising four times per week, they were able to lose a significant amount of body weight without losing any lean mass. Maintenance of muscle mass is crucial for preserving resting metabolic rate,7Stiegler P. Cunliffe A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss.Sports Med. 2006; 36: 239-262https://doi.org/10.2165/00007256-200636030-00005Crossref PubMed Scopus (284) Google Scholar which can help with long-term weight management.Although the study has several strengths, some limitations were also noted. For example, the sample size was very small (n = 23) compared to other studies in the field that involved 60 to 5828 participants.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar In addition, the very low dropout rate in the intensive lifestyle group (8%) is considerably different from previous reports that show dropout rates ranging from ∼20% to 30%.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The degree of weight loss observed by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar (17% from baseline) is also very high compared to other studies in the field, which report losses of ∼1%–5% from baseline. It is also striking that every subject in the intensive group lost weight, with the lowest amount of weight loss being 6% and the highest being 29%. In comparison, other trials show that approximately 20%–40% of participants are not responsive to therapy and lose no weight.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The adherence data, which indicates that participants attended 98% of weekly diet counseling sessions and 92% of exercise sessions over 8 month, also seems quite high.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar These concerns put into question the generalizability of the findings. This study seems to have recruited a highly motivated group of people with type 2 diabetes, which may not be representative of this population. Additionally, we question the feasibility of delivering such an intensive intervention to hundreds or even thousands of employees or those who do not work in a traditional office setting (e.g., truck drivers, nurses). In view of this, these findings should be interpreted with caution as these data are considerably different from what has been reported previously.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google ScholarAnother concern is the lack of follow-up for the intensive lifestyle group. It is truly impressive that these participants were able to lose so much weight, improve multiple parameters of metabolic health, and even achieve diabetes remission. However, without proper long-term care,10Flore G. Preti A. Carta M.G. Deledda A. Fosci M. Nardi A.E. et al.Weight maintenance after dietary weight loss: systematic review and meta-analysis on the Effectiveness of Behavioural intensive intervention.Nutrients. 2022; 14https://doi.org/10.3390/nu14061259Crossref Scopus (3) Google Scholar most of these individuals will regain their weight and their diabetes risk factors will return to baseline levels. This study would have been stronger if it included a long-term follow-up component, where subjects were contacted months or years after the trial to see if they were still following the interventions in the absence of intensive monitoring. These data would help to clarify whether the benefits of this workplace lifestyle initiative can be maintained over years.Challenges aside, the study by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar highlights the potential of worksite wellness programs to assist employees in managing their weight and improving metabolic health outcomes. This trial suggests that intensive work-based programs can play a critical role in helping to combat the obesity and diabetes epidemic. Since adults spend most weekday waking hours at work, worksite interventions are uniquely positioned to improve employee health.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar These wellness programs can also benefit the company by lowering healthcare costs, while boosting employee productivity. Since the passage of the Affordable Care Act, the availability of worksite wellness programs has increased, in part, due to the law's incentives for companies to implement such programs. Current estimates suggest that 84% of large companies (200 + employees) in the US provide a program in at least one area: smoking cessation, weight management, and behavioral or lifestyle coaching.3Kaiser Family Foundation2019 Employer Health Benefits Survey.2019https://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019Google Scholar However, most worksite-based programs result in only modest weight loss, likely because interventions tend to be low or moderate intensity and provide minimal supervision. In a recent randomized controlled trial by Yoshino et al.,1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar adults with obesity and type 2 diabetes were assigned to one of two work-based interventions: intensive lifestyle therapy or standard care. The intensive therapy group met weekly with a dietitian to receive personalized diet and behavioral weight loss counseling. The energy intake goal for this group was adjusted weekly to achieve 0.5%–1.0% weight loss and >10% weight loss over 8 months. Meal replacements were supplied to help meet energy intake targets. In addition, the intensive lifestyle group participated in endurance and resistance exercise four times per week for 60 min per session. In contrast, the standard care control group received basic diet and physical activity instructions, based on American Diabetes Association guidelines.4American Diabetes AssociationStandards of medical care in diabetes-2022 Abridged for Primary care Providers.Clin. Diabetes. 2022; 40: 10-38https://doi.org/10.2337/cd22-as01Crossref PubMed Google Scholar This group had minimal contact with the study team and only interacted with interventionists once per month for clinical measurements. After 8 months of treatment, the intensive lifestyle therapy group achieved 17% weight loss, with individual results ranging from 6% to 29%. Fat mass and visceral fat mass decreased while lean mass was maintained. Diabetes medication use decreased by 61% from baseline, HbA1c was reduced by 0.9%, and three participants achieved diabetes remission. Improvements in intrahepatic triglyceride content, pancreatic beta-cell function, cardiorespiratory fitness, and muscle strength were also noted. However, none of these benefits were observed in the standard care control group because the body weights of these participants remained stable. This study has several strengths. First, the intensive therapy included both diet and behavioral counseling. The former is essential to improve diet quality and the latter is crucial to modify behaviors that contribute to weight regain. Both of these counseling components are vital for long-term weight and glycemic control and should be incorporated into all work-based interventions.5American Diabetes Association Professional Practice Committee8. Obesity and weight management for the Prevention and treatment of type 2 diabetes: Standards of medical care in diabetes-2022.Diabetes Care. 2022; 45: S113-S124https://doi.org/10.2337/dc22-S008Crossref PubMed Scopus (30) Google Scholar Second, the participants met with study personnel on a weekly basis. This high level of interaction between subjects and the study team likely played a major role in the extreme amount of weight loss (17%) observed in this trial. Third, the intensive therapy included both an endurance and resistance training component. Exercise plays an important role in maintaining muscle mass during weight loss. In the absence of exercise, approximately one-quarter of the total weight lost is lean mass.6Willoughby D. Hewlings S. Kalman D. Body Composition Changes in weight loss: Strategies and Supplementation for maintaining lean body mass, a Brief review.Nutrients. 2018; 10https://doi.org/10.3390/nu10121876Crossref Scopus (45) Google Scholar Because the intensive lifestyle group was exercising four times per week, they were able to lose a significant amount of body weight without losing any lean mass. Maintenance of muscle mass is crucial for preserving resting metabolic rate,7Stiegler P. Cunliffe A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss.Sports Med. 2006; 36: 239-262https://doi.org/10.2165/00007256-200636030-00005Crossref PubMed Scopus (284) Google Scholar which can help with long-term weight management. Although the study has several strengths, some limitations were also noted. For example, the sample size was very small (n = 23) compared to other studies in the field that involved 60 to 5828 participants.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar In addition, the very low dropout rate in the intensive lifestyle group (8%) is considerably different from previous reports that show dropout rates ranging from ∼20% to 30%.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The degree of weight loss observed by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar (17% from baseline) is also very high compared to other studies in the field, which report losses of ∼1%–5% from baseline. It is also striking that every subject in the intensive group lost weight, with the lowest amount of weight loss being 6% and the highest being 29%. In comparison, other trials show that approximately 20%–40% of participants are not responsive to therapy and lose no weight.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar The adherence data, which indicates that participants attended 98% of weekly diet counseling sessions and 92% of exercise sessions over 8 month, also seems quite high.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar These concerns put into question the generalizability of the findings. This study seems to have recruited a highly motivated group of people with type 2 diabetes, which may not be representative of this population. Additionally, we question the feasibility of delivering such an intensive intervention to hundreds or even thousands of employees or those who do not work in a traditional office setting (e.g., truck drivers, nurses). In view of this, these findings should be interpreted with caution as these data are considerably different from what has been reported previously.2Penalvo J.L. Sagastume D. Mertens E. Uzhova I. Smith J. Wu J.H.Y. et al.Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.Lancet Public Health. 2021; 6: e648-e660https://doi.org/10.1016/S2468-2667(21)00140-7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,8Mulchandani R. Chandrasekaran A.M. Shivashankar R. Kondal D. Agrawal A. Panniyammakal J. et al.Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.Int J Behav Nutr Phys Act. 2019; 16: 134https://doi.org/10.1186/s12966-019-0896-0Crossref PubMed Scopus (22) Google Scholar,9Park S.H. Kim S.Y. Effectiveness of worksite-based dietary interventions on employees' obesity: a systematic review and meta-analysis.Nutr Res Pract. 2019; 13: 399-409https://doi.org/10.4162/nrp.2019.13.5.399Crossref PubMed Scopus (2) Google Scholar Another concern is the lack of follow-up for the intensive lifestyle group. It is truly impressive that these participants were able to lose so much weight, improve multiple parameters of metabolic health, and even achieve diabetes remission. However, without proper long-term care,10Flore G. Preti A. Carta M.G. Deledda A. Fosci M. Nardi A.E. et al.Weight maintenance after dietary weight loss: systematic review and meta-analysis on the Effectiveness of Behavioural intensive intervention.Nutrients. 2022; 14https://doi.org/10.3390/nu14061259Crossref Scopus (3) Google Scholar most of these individuals will regain their weight and their diabetes risk factors will return to baseline levels. This study would have been stronger if it included a long-term follow-up component, where subjects were contacted months or years after the trial to see if they were still following the interventions in the absence of intensive monitoring. These data would help to clarify whether the benefits of this workplace lifestyle initiative can be maintained over years. Challenges aside, the study by Yoshino et al.1Yoshino M. Yoshino J. Smith G. Stein R.I. Bittel A.J. Bittel D.C. Reeds D.N. Sinacore D.R. Cade T.W. Patterson B.W. et al.Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetes.Cell Met. 2022; 34https://doi.org/10.1016/j.cmet.2022.08.012Abstract Full Text Full Text PDF Scopus (0) Google Scholar highlights the potential of worksite wellness programs to assist employees in managing their weight and improving metabolic health outcomes. This trial suggests that intensive work-based programs can play a critical role in helping to combat the obesity and diabetes epidemic. Worksite-based intensive lifestyle therapy has profound cardiometabolic benefits in people with obesity and type 2 diabetesYoshino et al.Cell MetabolismSeptember 8, 2022In BriefMihoko et al. report that intensive lifestyle therapy provided at the worksite causes marked weight loss, increased cardiorespiratory fitness and muscle strength, and improved physiological factors involved in the pathogenesis of T2D (β cell function, multi-organ insulin sensitivity, and skeletal muscle/adipose tissue biology) in people with obesity and type 2 diabetes. Full-Text PDF